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Chronic Diseases and Translational Medicine 6 (2020) 79e86
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Review
Pulmonary rehabilitation for patients with coronavirus disease 2019
(COVID-19)
Lu-Lu Yang a,b, Ting Yang b,*
a
Capital Medical University, Beijing 100069, China
b
Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing 100029,
China

Received 27 March 2020

Available online 14 May 2020

Abstract

As a highly infectious respiratory tract disease, coronavirus disease 2019 (COVID-19) can cause respiratory, physical, and
psychological dysfunction in patients. Therefore, pulmonary rehabilitation is crucial for both admitted and discharged patients of
COVID-19. In this study, based on the newly released pulmonary rehabilitation guidelines for patients with COVID-19, as well as
evidence from the pulmonary rehabilitation of patients with severe acute respiratory syndrome, we investigated pulmonary
rehabilitation for patients with COVID-19 having complications, such as chronic pulmonary disease, and established an intelligent
respiratory rehabilitation model for these patients.
© 2020 Chinese Medical Association. Production and hosting by Elsevier B.V. on behalf of KeAi Communications Co., Ltd. This is
an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Keywords: Coronavirus disease 2019 (COVID-19); Pulmonary rehabilitation; Intelligence

Coronavirus Disease 2019 (COVID-19) has spread
worldwide and has become a global public health
emergency. The World Health Organization recently
declared the outbreak a pandemic. In accordance with
the Law of the People's Republic of China on the
* Corresponding author. Department of Pulmonary and Critical
Care Medicine, Center of Respiratory Medicine, China-Japan
Friendship Hospital, No 2, East Yinghua Road, Chaoyang District,
Beijing 100029, China.
E-mail address: zryyyangting@163.com (T. Yang).
Peer review under responsibility of Chinese Medical Association.
Production and Hosting by Elsevier on behalf of KeAi
Prevention and Control of Infectious Diseases,
COVID-19 has been classified as a Category B infec-
tious disease, with prevention and control measures for
Category A infectious diseases adopted against the
disease. Multiple COVID-19 diagnosis and treatment
guidelines have been released by the National Health
Commission of the People's Republic of China, all of
which have contributed to the gradual control of the
epidemic. According to the data released by the Na-
tional Health Commission, although more than 84,000
patients have been diagnosed with COVID-19, over
78,000 patients have now recovered and have been
discharged. Since patients with COVID-19 suffer from
various degrees of respiratory, physical, and psycho-
logical dysfunction, pulmonary rehabilitation is
equally important for both admitted and discharged

https://doi.org/10.1016/j.cdtm.2020.05.002
2095-882X/© 2020 Chinese Medical Association. Production and hosting by Elsevier B.V. on behalf of KeAi Communications Co., Ltd. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
80 L.-L. Yang, T. Yang / Chronic Diseases and Translational Medicine 6 (2020) 79e86
patients for the treatment of the disease.1 For this
reason, several pulmonary rehabilitation guidelines for
patients with COVID-19 have been published in China
to strengthen the pulmonary rehabilitation of admitted
patients and follow-up and health management of
discharged patients and thereby help the patients to
recover and return to society more promptly and safely.
Pulmonary rehabilitation
Pulmonary rehabilitation refers to the individualized
rehabilitation treatment of patients with chronic pul-
monary diseases after a detailed assessment. With ex-
ercise training as its core, pulmonary rehabilitation
comprises comprehensive interventions, including but
not limited to psychological and nutritional support, as
well as education and behavioral changes.2 The goal of
pulmonary rehabilitation is to not only improve the
patient's physical and mental conditions but also help
the patient return to family and society more promptly.
With the development of evidence-based medicine,
progressively more information has been obtained,
based on which it is recommended that pulmonary
rehabilitation should be the core of standardized
management of patients with chronic obstructive pul-
monary disease (COPD) and a treatment option for
patients with other chronic pulmonary diseases. The
“Global Initiative for Obstructive Lung Disease
(GOLD)” incorporated pulmonary rehabilitation into
the standard treatment for patients with COPD as early
as 2001.3 The “Healthy China Initiative (2019e2030)”
issued in 2019 has also emphasized the necessity of
including pulmonary rehabilitation in a chronic pul-
monary disease action plan.4 Furthermore, several
high-quality clinical studies have verified the benefits
of pulmonary rehabilitation for inpatients, outpatients,
and inehome patients. The benefits include improved
exercise tolerance in patients with chronic pulmonary
diseases, reduced number of hospital admissions and
length of hospital stays, enhanced health-related qual-
ity of life,5 improved respiratory muscle function and
relieved dyspnea,6 alleviated disease-related anxiety
and depression,7 and enhanced skeletal muscle func-
tion of upper and lower limbs.8,9
Necessity of pulmonary rehabilitation for patients
with COVID-19
At present, the main antiviral drugs that are rec-
ommended for the treatment of COVID-19 are inter-
feron-a (IFN-a), lopinavir/ritonavir, ribavirin,
chloroquine phosphate, hydroxychloroquine sulfate,
and arbidol. According to the summary of phased
treatment of patients with COVID-19 in China, the
clinical efficacy of lopinavir/ritonavir for antiviral
treatment is not obvious, and Lopinavir/Ritonavir is
associated with several side effects; hence, the drug is
not recommended for use at present.10 The indirect
evidence for efficacy of Ribavirin and IFN in the
treatment of COVID-19 has been mainly derived from
the evidence of the efficacy of the drugs in treatment of
infections caused by severe acute respiratory syndrome
(SARS) and middle east respiratory syndrome
(MERS).11,12 However, patients with COVID-19
treated with IFN-a 2b in combination with Ribavirin
have no significant improvement in the risk of death
compared to those treated with IFN-a 2b alone.13 The
latest research shows that chloroquine can effectively
inhibit severe acute respiratory syndrome coronavirus
2 (SARS-CoV-2) infection at the cellular level.14
Furthermore for patients with a history of local
epidemiology or other risk factors related to infection
(including travel history or exposure to animal influ-
enza virus), oseltamivir can be empirically added to the
treatment regimen.15 Some scholars also think that
remdesivir, darunavir/cobicistat, and favipiravir could
be used in the treatment of COVID-19. At present, a
number of randomized controlled trials are in progress
to evaluate the efficacy and safety of the above-
mentioned drugs for the treatment of COVID-19.
The three major components of the medical sys-
temdprevention, treatment, and rehabilitationdare
equally important. The primary clinical manifestations
of COVID-19 are fever, cough, dyspnea, and
myalgia16; however, severe cases can rapidly progress
to acute respiratory distress syndrome (ARDS). In
addition, some patients can develop acute myocardial
and kidney injuries.17 The latest pathological reports
indicate that the predominant pathological changes in
early-18 and late-stage patients are diffuse lung in-
juries, although some patients also suffer from intra-
alveolar fibrinous exudate and pulmonary interstitial
fibrosis. Moreover, the virus also affects other organs
such as the heart, liver, and kidneys to various de-
grees.19 These changes contribute to hypoxemia and
impaired cardiopulmonary and organ functions
throughout the body. Currently, evidence on the prog-
nosis of patients with COVID-19 is insufficient, espe-
cially for elderly patients in whom the disease is
complicated by other basic diseases. It remains unclear
whether the impairment of multiple systemic functions
is reversible or if the long-term existence of the virus
can cause physical dysfunction in these patients. In
addition, because COVID-19 has caused a public
 L.-L. Yang, T. Yang / Chronic Diseases and Translational Medicine 6 (2020) 79e86
emergency, patients with COVID-19 may demonstrate
different degrees of psychological disorders, such as
anger, fear, anxiety, depression, insomnia, and loneli-
ness, as well as a lack of cooperation and abandonment
of treatment due to fear of the disease.20 Even when
discharged, the patients may experience post-traumatic
stress syndrome. Therefore, prompt introduction and
continuous availability of pulmonary rehabilitation
services is critical for patients with COVID-19.
Evidence for pulmonary rehabilitation of patients
with SARS
Follow-up studies have shown that after discharge,
patients with severe acute respiratory syndrome
(SARS) can still suffer from symptoms, such as
restrictive pulmonary dysfunction, palpitations, hand
tremors, and exertional dyspnea, all of which affect
their daily activities and impair their quality of life.21,22
It has been suggested that these symptoms are associ-
ated with prolonged bed rest, adverse effects of steroid
medications, and residual pathological changes, such
as atelectasis, persistent alveolitis, pulmonary fibrosis,
and varying degrees of muscle weakness or dysfunc-
tion.23 In addition, a 1-year follow-up of patients with
ARDS showed that, survivors of ARDS exhibit
persistent functional disability one year after discharge
from the intensive care unit. Most patients have
extrapulmonary conditions, with muscle wasting and
weakness being most prominent.24 Compared with
SARS, pathological changes, such as pulmonary
fibrosis, have not been dominant in patients with
COVID-19; however, we speculate that damage to the
lung and other organ systems caused by SARS-CoV-2,
especially in severe patients with ARDS, may lead to
residual physical dysfunction of varying degrees. Thus,
the evidence for pulmonary rehabilitation of patients
with SARS provides strong support and reference for
the development of pulmonary rehabilitation programs
for patients with COVID-19.
Lau et al25 carried out a 6-week pulmonary reha-
bilitation program for 133 patients with SARS who had
been discharged after treatment. Each rehabilitation
session was conducted for 1.0e1.5 h, 4e5 times per
week. The interventions included 30e40 min of aero-
bic training at 60%e75% (up to 80%e85% for some
subjects) of maximum heart rate predicted using the
Chester Step Test to reach a score of 4e6 on the Borg
Rating of Perceived Exertion, followed by 3 sets of
upper and lower limb resistance exercises at 10e15
RM (repetition maximum, the maximum load that can
be repeated with 10e15 movements in each set) and
81
relevant health education. Compared with patients in
the control group who only received conventional care,
patients in the rehabilitation group showed significant
differences in 6-minute walking distance and
maximum rate of oxygen consumption during incre-
mental exercise. In addition, the isometric muscle
strength of the anterior deltoid muscle and gluteus
maximus, the grip strength of both hands (distal muscle
strength), and results of the 1-minute curl and push-up
test (endurance of abdominal and upper limb muscles)
were all substantially elevated in the rehabilitation
group. However, although the role-physical, role-
emotional, and social function scales of the SF-36
questionnaire had improved within 6 weeks in the
rehabilitation group, the pairwise differences were
insignificant, possibly due to the extensive physical
and psychological impacts of SARS on the patients
(especially elderly patients). Furthermore, patients who
were not reinstated (predominantly healthcare workers)
scored lower on almost all scales (except bodily pain)
than patients who were reinstated prior to the
completion of the intervention, indicating that prompt
reinstatement can help improve the patients’ quality of
life. Alternatively, a small sample study in China on 9
discharged patients with SARS who underwent 3
weeks of rehabilitation consisting of respiratory exer-
cises combined with deep breathing and stretching
exercises, low-to medium-intensity treadmill aerobic
endurance exercise, and direct-current iontophoresis
pulmonary physiotherapy, suggested that the perfusion
rate for pulmonary function of the patients was
significantly different from the baseline value. In
addition, the dyspnea level of the rehabilitation group
improved considerably compared to that of the control
group, while the resting heart rates of both groups
recovered to a certain extent.26
Pulmonary rehabilitation guidelines for patients
with COVID-19
Based on front-line expert consensus and refer-
ences, rehabilitation specialists in China have devel-
oped practical and feasible respiratory rehabilitation
guidelines for patients with COVID-19. The primary
instructions of these guidelines are as follows: (1) The
short-term goal of pulmonary rehabilitation is to alle-
viate dyspnea and relieve anxiety and depression while
the long-term goal is to preserve the patient's function
to the maximum extent, improve his/her quality of life,
and facilitate his/her return to society. (2) It is neces-
sary to perform comprehensive assessments before
starting the rehabilitation program. For example,
82 L.-L. Yang, T. Yang / Chronic Diseases and Translational Medicine 6 (2020) 79e86
clinical and exercise risk assessments should be per-
formed based on the patient's clinical symptoms, vital
signs, auxiliary examinations, imaging, comorbidities,
contraindications, etc., whereas quality of life, daily
activity endurance, and psychological and nutritional
assessments should be conducted in the form of
questionnaires. The results of these assessments can
then be combined with the patient's aerobic endurance,
muscle strength, balance, and flexibility to formulate
an individualized and progressive rehabilitation pre-
scription. The prescription content mostly includes: A.
Aerobic exercises: walking, fast walking, jogging,
swimming, etc., starting from low intensity and grad-
ually improving the intensity and duration, 3e5 times a
week, 20e30 min each time. B. Strength training:
progressive resistance training is recommended. The
training load of each target muscle group is 8e12 RM,
1e3 groups/time. The training interval of each group is
2 minutes, 2e3 times/week, and the training load is
increased by 5%e10% every week. C. Balance
training: Patients with balance dysfunction should be
involved in balance training, including unarmed bal-
ance training and balance training instrument. D.
Respiratory training: if the patient has symptoms, such
as shortness of breath, wheezing, and difficulty in
expectoration after discharge, respiratory mode
training, such as body position management, adjust-
ment of respiratory rhythm, traction of respiratory
muscle group breathing exercise, and expectoration
training, should be arranged in combination with the
evaluation results. E. Health care training for using
traditional Chinese medicine: it is mainly for light and
ordinary patients and discharged patients. If there is no
contraindication (such as limb dysfunction and
abnormal consciousness), it is recommended to carry
out Baduan jin, Twenty-four Simplified Tai chi, Six-
word Qigong, etc., 30e50 min each time, once a day.
(3) All rehabilitation should be carried out under the
premise of safety. In case a patient shows peripheral
capillary oxygen saturation (SpO2) < 88% or develops
symptoms, such as palpitations, sweating, chest tight-
ness, and shortness of breath, which are deemed un-
suitable for rehabilitation by the clinician, then the
rehabilitation program should be terminated immedi-
ately. (4) For mild and moderate cases, rehabilitation
interventions should be introduced as early as possible.
In contrast, for severe and critical cases, life-saving
measures should be prioritized when the patient's
condition is unstable or the disease is still progressing.
In such cases, pulmonary rehabilitation interventions
should be introduced only when the patient's condition
has stabilized. In addition, in view of safety and human
resources, movement of severely or critically ill pa-
tients should be limited to their bed or bedside. Once
discharged, patients should continue individualized
rehabilitation under the premise of strengthening pro-
tection and prevention against other infectious diseases
such as cold. (5) Compared with general rehabilitation
for patients with chronic diseases, the most distinctive
characteristic of rehabilitation for patients with
COVID-19 is the infectivity of the disease. Therefore,
operations that can increase the risk of infection, such
as instructed cough, expiration training, and tracheal
compression, should be minimized. A sealed plastic
bag should be used to cover the mouth during expec-
toration to prevent infection. In addition, pulmonary
rehabilitation of patients with COVID-19 should be
carried out mainly through educational videos, bro-
chures, remote consultations, or online teaching so as
to save protective equipment and avoid cross infection.
(6) Evaluation and monitoring should be conducted
throughout the pulmonary rehabilitation program.27,28
An example of the rehabilitation of a patient with
COVID-19 is provided below.
Patient A is a male, 50 years old, and critically ill
with COVID-19. Prior to rehabilitation, the patient was
treated in the ICU for 1 month before he underwent
hormone therapy for over 1 month. The computer to-
mography (CT) displayed diffuse pulmonary lesions in
both lungs, as shown in Fig. 1. Table 1 lists the patient's
assessment results prior to rehabilitation, and Table 2
lists the patient's individualized rehabilitation pre-
scription based on the assessment.
Thoughts on pulmonary rehabilitation of patients
with COVID-19 complicated with chronic pulmo-
nary diseases
For patients with COVID-19 complicated with
chronic pulmonary diseases, such as COPD, bronchial
asthma, and pulmonary interstitial fibrosis, in addition
to performing an assessment and developing a pre-
scription based on the rehabilitation guidelines, the
following instructions should be followed: (1) Ensure
the continuation of standardized basic medications and
a reasonable diet. (2) Promote smoking cessation, flu
vaccination, and Streptococcus pneumoniae vaccina-
tion. (3) As patients with COVID-19 having chronic
pulmonary diseases often have excessive airway se-
cretions, expiration exercises should be performed in
addition to general airway clearance exercises to
facilitate sputum excretion and reduce the exhaustion
due to coughing. In addition, auxiliary techniques,
such as the application of oscillatory positive
 L.-L. Yang, T. Yang / Chronic Diseases and Translational Medicine 6 (2020) 79e86 83

Fig. 1. Diffuse pulmonary lesions in both lungs of the COVID-19 patient.

expiratory pressure (OPEP), can be utilized. (4)
Appropriate oxygen therapy should be provided during
exercises. Patients with chronic pulmonary diseases
can develop hypoxemia at rest. Subsequently, when
exercising, as the interval for red blood cells to pass
through the alveolar capillaries is shortened, the
ventilation flow rate disorder increases, and oxygen
intake decreases. Meanwhile, an escalated breathing
rate causes pulmonary dynamic hyperinflation and gas
trapping, which increases the end-expiratory lung
volume, dead space ventilation and work of breathing,
thereby further reducing blood oxygen saturation. In
contrast, introducing oxygen therapy during exercise
can meet the elevated metabolic demands, prevent
hypoxemia, and reduce pulmonary dynamic hyperin-
flation, thereby improving the effect of exercise, while
allowing an increase in the intensity and duration of the
exercise. Hypoxemia during exercise is regarded as the
indication for requirement of oxygen therapy (SpO2 at
88%e90% or a relative reduction of 2%e5%, lasting

Table 1
Assessment results before rehabilitation.
Assessment Items Assessment Result Suggested Issue
Breath-hold test Less than 10 seconds (normally 30 seconds) Impaired lung function
1-minute step test Heart rate before and after the test 102e124 beats/minute Severely declined cardiopulmonary endurance
Blood oxygen change 97%e94%
Borg Dyspnea Scale score 0e2
Squat Cannot complete independently Lower limb muscle atrophy and reduced
muscle function

Table 2
Individualized rehabilitation prescription.
Prescription Items
Improve dyspnea
Airway clearance
Respiratory muscle exercise
Thoracic expansion exercise
Activity
Resistance exercise
Nutritional support
Content Required Equipment
Diaphragmatic breathing þ constricted breathing, 10 minutes, 3 Bare hands
times/day
Expiration training þ sputum excretion device, 15 minutes, 1 time/ Sputum excretion and breathing trainer
day
Non-threshold load training for the inspiratory muscle, started from Respiratory muscle trainer
3 cm H2O and slowly increased thereafter, 10e15 minutes, 1 time/
day
Stretching, 5 minutes, 1 time/day Bare hands
10e30 minutes, either walking or stepping, target heart rate 124 Heart rate monitor and oximeter
beats/minute, Borg score 2, blood oxygen no less than 90%
Bare hands, yellow elastic band, big muscle group, 10 minutes/time Elastic band
Protein powder for muscular dystrophy, 1e12 g/kg Protein powder
84 L.-L. Yang, T. Yang / Chronic Diseases and Translational Medicine 6 (2020) 79e86
for 0.5e5.0 min). The goal of oxygen therapy is to
adjust the oxygen flow rate to maintain the SpO2
within the range of 90%e92%. In order to increase the
exercise effect, the oxygen flow rate can be increased
according to the exercise intensity to maintain the
SpO2 at about 95%.29 (5) Thoracic kyphosis correc-
tion: Due to long-term dyspnea, cough, etc., the work
of breathing in patients with chronic pulmonary dis-
eases often increases, which leads to the formation of
abnormal breathing patterns. The resultant chronic
pulmonary hyperinflation usually causes enlargement
of the anterior and posterior diameters of the chest,
thereby resulting in barrel chest or other chest de-
formities. A study of 143 young patients with cystic
fibrosis showed that in patients over 15 years old, the
condition of 77% of females and 36% of males was
complicated with thoracic kyphosis deformity of more
than 40 .30 Since this deformity can inhibit airway
clearance and increase the work of breathing, it is
important to incorporate physiotherapy, such as chest
and muscle stretching and intensive training, in a
comprehensive pulmonary rehabilitation program for
thoracic kyphosis correction.
Exploration and implementation of intelligent
pulmonary rehabilitation for patients with
COVID-19
The strong infectivity of COVID-19 and dispersal of
discharged patients make it difficult to realize remote
pulmonary rehabilitation. At present, there is insuffi-
cient research on the clinical implementation of remote
pulmonary rehabilitation. In recent years, rapid devel-
opment in Internet technology has facilitated the
implementation of remote monitoring and mobile in-
telligence technologies. The use of information and
communication technology together with wearable
devices has made it possible to practice intelligent,
digital remote rehabilitation for patients with chronic
pulmonary diseases, the effectiveness and safety of
which have been proven non-inferior to those of
traditional approaches.31,32 Based on this, we have
pioneered the implementation of Internet-assisted
pulmonary rehabilitation in Wuhan's mobile cabin
hospitals. During the process, rehabilitation content is
imported into a dedicated rehabilitation mobile appli-
cation in text and video formats, including barehanded
aerobic training, resistance training with elastic band,
and respiratory muscle traction exercise. Once a pa-
tient has downloaded the application, he/she can
directly obtain an individualized rehabilitation pre-
scription through the application, followed by video
training and recordings of rehabilitation exercises. In
addition, the mobile app is capable of functions, such
as symptom assessment and recording, automatic re-
minders for medication intake, and health education.
All acquired data are transmitted to the management
terminal of the medical care platform through infor-
mation and communication technology, so that the
medical staff can remotely monitor and evaluate the
information provided by the patient on a regular basis
and introduce corresponding measures and in-
terventions. This randomized controlled clinical trial to
evaluate the benefits of rehabilitation is still ongoing. It
is expected that this remote model will not only reduce
direct contact and exposure between doctors and pa-
tients, thereby preventing infection and saving pro-
tective equipment, but also provide long-term benefits
to patients, such as improvement in cardiopulmonary
endurance, recovery of physical function, and reduc-
tion of anxiety and depression, thereby promoting pa-
tients' return to society with an enhanced quality of
life.
Conclusion and outlook
The development of rehabilitation medicine has
been promoting the transformation of traditional, pas-
sive, and fractured medical care models into a human-
oriented healthcare system that covers all stages of life.
Pulmonary rehabilitation should be provided
throughout the diseases management process, regard-
less of whether the patient is hospitalized or at home. In
addition, rehabilitation prescriptions should be indi-
vidualized based on the patient's specific condition. The
effective incorporation of pulmonary rehabilitation into
disease management and a patient's daily life, so that it
becomes a conscious behavior, can provide long-term
benefits to both the patient and his/her family. With
the deepening of the understanding of COVID-19, an
increasing number of patients have recovered. Pulmo-
nary rehabilitation for these recovered patients has
become a major challenge for medical staff, the reso-
lution of which requires multidisciplinary collaboration
and joint exploration so that evidence-based, high-
quality support can be provided. In addition, the
implementation of both traditional and research-based
pulmonary rehabilitation provides valuable experience
for clinical and rehabilitation medicine practices, which
is necessary to implement the “Healthy China” concept.
 L.-L. Yang, T. Yang / Chronic Diseases and Translational Medicine 6 (2020) 79e86 85

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Edited by Yi Cui